S 2358APPI ICANTTO FILL IN INFORMATION WITHIN RED LINES -USE BALL POINT PEN ONLY
CITY OF CUPERTINO BUILDING - ELECTRICAL
BUILDING DIVISION APPLICNIION/PERMIT PLUMBING-MF,CHANICAL
BUILDING PROJECT IDENTIFICA'PION
PERMIT NO.
S 2358
tlU lt. NG ADDRF3
SANITARY NO.
APPLICATION SUBMITTAL DATE
3�&
U -r
OW' 'H'S NAME: 1 PHONE:
LNIC
al
CONTRACT vA
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❑
CONIROLp
A CHITECTA;NGINEEN: LIC NO
I
ADDRESS:
CONTACT: PHOP .
BUILDING PERMIT INFO
❑ Consultant Fees Paid by Applicant (Initial)
BLDG ELF:C'IPLUMB MECH
LICENSED CONTRACTOR'S DECLARATION
1 Inner, affirm but I am licensed under pmwlsiana of Chvpter 9 moratoria,
QTY ELECTRIC PERMIT FHE
JOB DESCRIPTION
PERMIT'ISSUANCIi
with Section 90(Bof Division3.I`mm Busincssand Pn Tessler, Cnde,and my IkOloe is
in full forecand affect.
RESIDENTIAL:
❑SFDWL ❑ KITCHEN REMODEL
APPLIANCES -RESIDENTIAL
License Class Lien
Dare Cuntracmr
[]ADDITION [I PLUMBING RE -PIPE
❑STRUCTURAI,
MODIFICAUON
❑INTERIOR El CHIMNEY REPAIR
IMPROVEMENT SWIMMING POOLS
ARCHITECT'S DECLARATION❑MULTI-UNIT
1 understand my plans shall he used as public records
PANELS
UP TO AXI AMPS
Licensed Professional
201-1000AMPS
OWNIiR-BUILDER DECLARATION
1 hereby allure that 1 am exam,, Oom IM1e Conmacmr's I.,cram I.aw Bn IM1e
following reason. (Section 7031.5. Business and Professions Cale: Any city or county
C1BATH REMODEORF,PAIR ElD17MOLITION
❑ O'IHLR
OVER 1000 AMPS
SIGNS ELECTRICAL
which requires a permit to construct. alter, improve, dcomish, or repair any structure
SPECIAL CIRCUI RMISC.
prior to its iswance. also requires the applicant for such permit to file a signed statement
Thal he is licensed pursuant o the provisions of the Contractor's License Law tChupter 9
(commencing will, Section 700E of Division 3 order Business and Professions Code) or
TEMP. METER OR POLE TNST
COMMP.NCIAI:
That he is "coups Therefrom and the basis for Ne alleged exemption. Any violation of
❑ NEW BLDG/ADDITION ❑ DEMOLI'T'ION
Section 7031.5 by any applicant for a ,narit subjects the applicant to a civil penalty of
not more than five hundred Jallars ($D0y
D 1, as owner al'the pr,,cy,cr my amployeee with wagcs as theirsolecnmµ:nsatim,
will du the work, and the slrvctum is not intended croacml for sale (Sec. 7044, Business
POWER DEVICES
TENANT ❑ FOOD SERVICE
IMPROVEMENT
THBR
SWIMMING POOL ELECTRIC
amt Pmfe,sinns CMe: The Contractor's License law does nm apply To an owner of
OUTLIffS-SWITCHES-FIXTURES
NEW RISIDEMIAL ELF.CfR SO IT.
progeny who builds or improves thereon, and who does such work himself or through
his own employees, provided that such improvements am not intended or a1kred for
sale. 11, however, the building of improvement issold within once yanr of It in
�1'O, PL ARBA
�L-f
$/SQ. I?.
mer- builder will Tom the burden of proving Thai he did not bmlJ of improve for Cur-
pre of sale.).
VT(yl1, as manor of the pmparty am exclusively contracting with licensed contmetm, Ta
iinstruct The project (Sec. 7194. Business and Prof"si cls Coda)'fhe Contrncmr's Li-
'AL:
nseLowdresnotapplyloanownerofpropenywhohuild, or improves Thereon. and
Q'I'Y. PLUMBING PERMIT FEE
who contracts for such pmjeels with a contortionist licensed par,mme to IM1e Contractors
License To,
I am eacmpl under Sec. . B & PC for This reason
PERMIT ISSUANCE
D
ALTER - BRAIN & VENT- WATER TEA)
VALUATION
WOORKSRKE COMPENSATION DECLARATION
BACK FLOW PROTECT. DEVICE
1 hereby off mT under penalty of perjury sone of The following Jedmations:
370 of Cunwm nrCode, for the Worker's Grmpcn-
on, as and will for by 3]IXI of Uc Labor Code for The padormuncc of Cha
rmi Ss
DRAINS - FLOOR, ROOF, AREA. COND.
STORIES
'I'VPF. CONSTRUCTION
which this parent is issued
volfr hick this
work
FIXTURES -PER 'IRAP
have rAer'
El 1 have and will maintain he Far Compensation work mr ce, h require) by Section
3700 of the lathor Crdc, for he performance nRhc work for which lM1is permit is issued.
OCC GROUP
AI'N
GAS - EA. SYSTEM. I INCA OUTLETS
My Worker's Compensation Insurance varier and Pul'my immhar me
Crucial: Policy Na.:
GAS - EA. SYSTEM OVER 4 IRA)
GRF.ASFANDUSTRL WASTE INTERCEPTOR
CERTIFICATE OF EXEMPTION FROM WORKERS'
COMPENSATION INSURANCE
BUILDING DIVISION FEES
(Hakwetiomnacdoot bacomplatcsl dthcptmit is foronchunJreddollon($IW)
or less.)
GRBASETRAP
PLANCHECK FEE
I certify that in The performance orthe work for which this Permit is issued.I shall
ecmsubject not employ any person in any manner so or to bne subjeco the Workers' Cooper-
SEWER - SANITARY - STORM Fit. 20D IT.
ENERGY FEE
WAI Bit HEATER WNENT/ELECTR
sarins Law, of CaliPomul. Date
Applicant
GRADING I2C
NOTICE TO APPLICANT': If, her making This Cenificam of Usemptiun, you .should
become mbjm To the Wodc', Compensation provisions of the labor Code, you must
WATER SYSTEMARGTING
SOILS PER
forthwith comply with such previsions or this pemnil shall be deemed revoked.
WATER SERVICE
CONSTRUCTION LENDING AGENCY
I hereby affirm fiatthem iso aurtraction leadingagency for The petinrmanceof
The work for which This permit is issued (See. 3097, Ci, C.)
Lenders Name
NEW RESIDENT 'I Al. PLMB. SQ. lel'.
PAIR
m Receipt#
TOTAL:
T(YTA
Lender's Address
inbommmn is
BUILDING FE
1 Gantry that I have mad this application and state another, above
commit. l agree to comply with all city and county ordinances and slate laws relating to
building construction, and hereby authorize repmecmmives of This city m enter upon the
QTY MECHANICAL PERMIT FEE
SEISMIC F.
PERMIT ISSUANCE
F.LECIRIC 'E
move -mentioned p,,,,cny far inspection purposes,
(We) agree m save, indemnify and keep Tantrums; the City of Cupertino against
ALTER OR ADD qD MECH.PLUMBING
FEE
liabilities.judgments, costs and expenaa which may in any way same against said City
in consequence of the grating of this permit.
AIR HANDLING UNIT(TO I0.000CFM)
APPLICANT UNDERSTANDS AND WILL C PLYWITH ALL NON -POINT
SOURCF,Jj'GU kHONS.
AIR HANDLING UNIT(OVIiN 10,(NXI CIM)
TRUC' O TAX
HOUSING MITIGATIO
ljp AL 10—
ldlSi
EXHAUST HOOD (WIDGET)
sure of ApplicanVCnmmm Date
HAZARDOUS MA'T'ERIALS DISCLOSURE
HE AT I NO ON I I( IO 100.000 BTU)
Will the applicant ur future huilding occupanl,tac nr hmiL lmzallou, material
as defined! by The Cupertino Municipal Cade. Chapter 9. 12. uad the Health and Safety
Code. Section 25532(a)'
IMATINC, UNIT (OVER 100JNJ BTU)
VENTILATION PAN (SINGLE RESID)
❑Yes 0 N
-Date
PAID
Ra M
Will The applicant or future building use equipment or devicmes which
aminas as Refitted by by the IM1e Bay Agee Air Quality Manegcenl
t h:vardous air cnmnt
V
BOILI3R-COME (THE OR 100.000 BTU) J
AL:
BOILER-COMP(OVER IIX1,1%1I1 BTU)
issricTl
El Y11 No
CONDITIONER
I have most TM1e havudous mmcrids requirements,requirements,under Chapter 6.95 of Ne Call -AIN
i-
RsMa Health & Safety Code, Seer a, 25505.25533 and 255.9. I to derar al Ohm if dr
ISSUANCG DATE /f
j�
NEW RESIDENTIAL. MF,CIL SQ. ET.
onsihility to notify the cupant
building Joe, not cuntly have a tenant, that it is my mspoc
currently
/ O— /
/�
of the milonenenu which mast be met prior m issuance of a Crr iticaav of Occupancy.
ISSUED BY:
TOTAL:
Owner or authorized agent Data
OFFICE